11 July 2012 9:57 AM

Credit where it is due – Andrew Lansley has gone where no previous health secretary has ventured for 60 years in his Social Care White Paper being published today. It will say that Councils must provide low-interest loans to cover care-home fees from 2015, and that there should be a limit on how much any individual is expected to pay. The Paper will also recognise the contribution made by family carers, will announce more money for specialist housing as well as setting out how more people can be looked after in their own home rather than being forced into a nursing home.

It was Derek Wanless in his second report of nearly a decade ago who projected that between 2005 and 2025 there would be an increase in demand for elderly care of 54%, and this has been borne out by the tightening of Council criteria for providing social care to only those with substantial or critical needs. At the same time thousands of care home places have been lost due to a combination of lack of funding, EU regulation and a move to care-at-home, which in the case of some of my old patients left them lonely, isolated and with no option for company.

However campaigners won’t be happy. There remains a blank in the Paper where it should say what the limit is on how much will have to pay – what the cap will be on personal liability for social care costs. And this will remain a blank for probably another two years. The risks here are both that people will continue to think that they won’t have to pay for care and don’t save or plan for it, and that there will be a delay in people taking out insurance to cover their fixed liability. Another unsolved problem that Mr Lansley cannot afford to tolerate are the numbers of elderly who remain in hospital because there is no care home placement or care-in-the-community package available. This can only get worse if more resources are not found.

Fundamentally there is no way that we can get around the fact that we will all need to plan to pay for social care, and we need to accept that we should also plan to take responsibility for our elderly relatives while we are able. We have been spoilt by the welfare state and the tough times we are in are partly due to our profligacy. Wouldn’t it be better to get all the bad news out of the way, let us get on with accepting we have to take more personal responsibility for social care and start planning for it?

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09 July 2012 4:37 PM

Death is a difficult subject, a modern day taboo almost. However discussing it is made harder by professionals not taking the time to talk to patients and their families about the process and choices. A letter in the Daily Telegraph today raises the issue of the unpredictability of the event of death. I expect we all know of someone who was given six months to live and lived six years; and the converse can be true with people dying much sooner than expected. The grief of losing a loved one is tremendous but if given warning, how their end-of-life care is managed makes a huge difference.

The concern being expressed in the letter today was of end-of-life care decisions being made without the consent of the patient or their family, or even that decision being made for capacity reasons stating that “Other considerations may come into reaching such a decision, not excluding the availability of hospital resources”. This will be scaremongering in some hospitals but sadly true in others where the pressure on beds, callous staff or the lack of home support for the dying mean that staff make hasty decisions without proper discussion or consent. Anxiety was also expressed about the Liverpool Care Pathway, which got its name having been developed at the Royal Liverpool Hospital in the 1990s, where fluids and drugs are with-held in a patient's final days and is used with 29 per cent of hospital patients at the end of their lives.

That this ‘care’ pathway should be applied without discussion is a travesty; a betrayal of the trust put in health professionals on whom we depend to nurse our relatives when we as family are unable to provide the necessary care. This is another example of NHS paternalism against which we as the patients and public must fight. There was a thread on twitter last week about the NHS constitution and how to raise its profile and the responsibilities, rights and redress contained therein. I suggested that we all get a summary copy of the constitution when we have an NHS appointment so we can have the information we need. I honestly think that unless and until we the public begin to have higher expectations of NHS professionals and hold them to the account, many of us will die waiting for them to take the initiative. The era of being a passive patient is over.

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06 July 2012 1:31 PM

A mother told the story on the radio yesterday of her infant son’s time in Leeds Hospital and the strain it had put on her family despite being local. He survived, but Leeds is one of the hospitals that is losing is children’s heart unit because it doesn’t see enough patients to be considered safe. This is a cautionary tale, because England has too many hospitals altogether, and for reasons of safety and financial sustainability we are all going to have to get used to going to hospital less but traveling further when we do. The trouble is, many have known this for decades yet gone on pouring money into NHS hospitals.

Although there was good news out yesterday in that 377 NHS organisations are not over-spending tax-payers money and are in the black, the bad news was that 34 NHS organisations are in the red and of these, 31 are hospitals. In other words, 31 hospitals are overspending and this is to the tune of £356 million. This is slightly less than 8% of all hospitals, but digging a little deeper into the NAO report on 'Securing the future financial stability of the NHS' showed that 51 more NHS organisations (another 12%) were only just in the black and that many of them had received extra money during the year in order to keep them solvent having blown their original budget.

PFI - Private Finance Initiatives - are in the frame as one of causes of hospital debts. Introduced to the world by Norman Lamont in 1992 they were formalised by Labour with their formation of Partnerships 2000, a PFI management body. Essentially PFI offers the chance for a hospital to take on a mortgage to support a redevelopment or expansion of their buildings. The private sector was already building most public facilities but the PFI also enabled the design, financing and operation of the new build to be carried out by the private sector as well as taking on some or all of the associated risks. PFI provided the large sums of money required to redevelop a hospital without increasing public debt - more so because PFI liabilities were controversially kept off all departmental balance sheets, thus enabling the Department of Health to circumvent their departmental spending limit. It was the only show in town if you were a hospital chief exec wanting to expand your domain, but many hospitals now basically have a credit card bill that they are struggling to pay.

We already knew back in the 90's and even more so in the noughties that we could not go on doing what the now chief exec of the NHS, Sir David Nicholson, calls 'business as usual'. Hospitals are expensive to run and much of what happens in hospital can take place in the community or even the home. There is nothing intrinsically wrong with PFI but since the first PFI hospital was opened by Tony Blair in April 2000, another 104 PFI deals have been signed off by the Department of Health. What were they thinking? We already had too many hospitals - and some of them are now saddled with debts that consume 10% of their annual budget and empty floors they can't fill. Who were the lawyers that drew up such punitive contracts? Who were the civil servants who merrily maxed out the NHS credit card? Where was the strategic plan that guided hospital expansion? Who was thinking about sustainability in a sector where up to 70% of funding goes on wages? Where is the accountability?

Not only do we now have a debt mountain but we still have too many hospitals, too many beds, too many clinicians doing things as they always have. PFI has in some cases made the situation worse with certain hospitals too large, too costly and with too much capacity. With the exception of the children’s heart units - which took over ten years from recommendation of closure to the decision being taken yesterday - there is still the sound of silence when it comes to any communication with the public that radical transformation (i.e. hospital closure) has to take place to keep the NHS safe and affordable. This children's heart unit decision could be the start of a new, honest dialogue with the public – we’ll see if the opportunity is taken.

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03 July 2012 2:23 PM

The media is buzzing today with the Barclay's Bob 'crazy' Diamond falling on his wallet sword story. Great gags are going around such as will it take three days for his resignation to clear? Which of the 5,000 Barclay Boris bikes will he depart on? That he is changing his name to Halfpenny Zirconia. Jeremy Warner and Rob Cooper cover the story thoroughly.

What's not funny is the extra that we have all paid due to the manipulation of the inter-bank lending rate which I doubt anyone could begin to calculate, certainly not on an individual basis. Many financial institutions, credit card agencies and mortgage lender set their interest rates relative to Libor (the London Interbank Offered Rate is the average interest rate estimated by leading banks in London that they would be charged if borrowing from other banks), so if Libor is rigged to be artificially high then we all pay more. As you can imagine it's more complicated than that and this scandal is not new, it surfaced in the 2008 economic crisis and 16 banks are currently being investigated for Libor fixing as a low rate can suit them too.

But even more serious than this is the cultural fallout: the total loss of trust, the flagrant greed, the justification of fraud and the indifference shown to the public. And while Crazy Bob has the limelight in the UK today, another story of equal iniquity has surfaced in the USA where the British pharma giant GSK has been fined $3 BILLION for fraudulant and criminal activity. Will Andrew Witty now join the ranks of Rupert Murdoch and Bob Diamond and have his regular invitation to Number 10 withdrawn?

When I was growing up, it was often said that those in positions of leadership had to accept that their standard of behaviour should be higher than average - above suspicion, exemplary and if necessary, sacrificial. 'With great power comes great responsibility' may have been just a line in Spiderman but as children we took it seriously.

This isn't a banking crisis, or a pharma disaster or a political emergency but a crisis in leadership, and change has to come from the top. Our leaders, in whatever field, need to know that nothing they say matters any more. Unless the public - including today's children - see leaders behaving with virtue, trust will not be regained and corruption will proliferate. Fraud needs to be prosecuted at the individual level and white-collar crime seen not to pay. Having just spent 10 days in Kenya where there are anti-corruption signs on the road-side, it is a tragedy to think that they are just as needed here in the UK. Is this what we have come to?

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28 June 2012 6:31 PM

Without having to think very hard, I can name five of my friends who in their forties have been diagnosed with cancer. For all our sophisticated medicine, cancer remains the leading cause of premature death. Last week we heard from Paul Burstow, the Lib Dem social care minister that England’s 20 cancer networks are facing financial cuts. Today, the research organisation I work with publishes the report "Cancer Commissioning - Making the reforms work for patients" on just how important these Cancer Networks are and that to jeopardise them through a reduction in funding risks losing the progress that we have made on cancer over the past few years.

Cancer Networks were introduced in 2000 to encourage the providers of cancer care and the commissioners of cancer care (those who buy, monitor and evaluate services) to work together in order to deliver quality, personalised cancer services to patients. They have over time become widely acknowledged in many areas to have transformed patient’s experiences and outcomes. The Networks have achieved what much of the rest of the NHS still strives for, that being an integrated approach between hospital and community services, sharing best practice and involving cancer patients and the groups that represent them.

Survival rates for the ‘big four’ cancers – breast, colon, lung and prostate – have improved over the last five years, with figures showing that we are finally catching up with other countries where survival has been better. The 2020Health report argues these improvements in patient outcomes are “directly attributable” to the introduction of Cancer Networks. One former NHS pharmacist told us that before Networks, cancer care was chaotic and poorly coordinated. Networks transformed both the quality and efficiency of the care patients received.The Networks have the combined expertise that individual GPs, doctors and specialists lack and access to their wealth of knowledge has ensured that many more people have been diagnosed promptly and accurately. Yet only today I heard of five members of one Network being given their notices by a PCT - this cannot be in the best interests of patients.

As with the rest of the NHS, there is room for improvement when it comes to accountability for the care given. Strengthen the mechanisms of accountability and we will improve how we plan and manage cancer care. We should know what the 1 and 5 year survival rates are for our local health trust (PCT) or their replacement GP run Clinical Commissioning Group, along with how many people don't have their cancer diagnosed until they reach A&E and how advance it is. Only then will we as the public have the relevant information on how well their local NHS is performing. Failure to have this knowledge, and any changes that weaken Cancer Networks could literally be the difference between life and death.

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26 June 2012 6:02 PM

Black holes are not just a cosmic phenomenon. Look inside the NHS and you will find at least 20 hospitals, according to the Standard and Poor credit rating agency, that have insurmountable debts. For years we have done nothing but watch and wonder until today, as Andrew Lansley, Secretary of State for Health has launched a bold rescue mission to South London Healthcare NHS Trust, a triumvirate of financially failing hospitals.

This rescue team of doctors, administrators and accountants will need to take a giant step for mankind: they will need to insist that NHS care moves into the 21st century, close some units and remove some of the services traditionally delivered at the hospitals into the community. It usually takes a crisis for radical new thinking and game-changing innovation to be adopted and this is an opportunity that should not be missed. We already have the technology and telehealth that can mean many people don’t have to travel to a hospital for an appointment or treatment, but transformation will require GPs, the social services and hospitals to cooperate in a whole new way.

Apart from the spectre of closing some services, the other great political challenge will be allowing this collaboration in the face of choice and competition. This will require a frank admission from politicians: that choice cannot be universal and that we should allow certain budgets to be pooled. When it comes to choice, there are services where it is financially viable such as choosing your GP, where you have an X-ray or cataract removed or between medical and surgical treatment. However there are many times where such choice is costly and unfeasible: A&E, specialised surgery and long-term condition care being examples.

The barrier to efficient health and social care collaboration has been the fact that social care is means tested, but to continue to see that as an insurmountable problem will prevent solutions being found to one of the huge drivers of NHS hospital costs: unplanned elderly admissions and longer in-patient stays due to lack of community support. With an ageing population it is vital that now, on the back of the decision to intervene, we don’t miss this opportunity. To find a short term financial fix would be a disaster. While European politicians dig ever deeper debt holes, Andrew Lansley can now lead the way on facing the reality that radical redesign service delivery is the way to deal with debt and one of the key steps to ensuring that we have a sustainable NHS that doesn’t go supernova.

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22 June 2012 2:37 PM

The Secretary of State for International Development, Andrew Mitchell, has given interview to the New Statesman in which he essentially dismisses the views of the elderly, but is I hope now sincerely regretting the inference. No matter what the subject is, to imply that the over 65’s are out of touch rather than a source of wisdom and sagacity is what you’d expect to hear from a rude teenager, not a Minister who has been a clear voice of reason in the debate on international aid. It’s even more surprising when so when many of the countries that the Department for International Development (DfID) supports are those in which the elderly are rightly revered and respected. I am proud that Andrew and our Prime Minister have made such a strong and sincere statement of commitment to those who through no fault of their own face a daily struggle for survival.

In the past few days I have been seeing for myself the life-changing impact of some of the money that we as a country donate to Kenya. For westerners it may be the land of safaris, but for many Kenyans who have no access to the clean water, electricity, healthcare or sewerage systems that we take for granted, every day is a challenging journey. Millions of people live in slums. Malaria, TB and HIV are still the biggest killers. Kenya still has one of the highest maternal death rates in the world. I have yet to talk to a child in a slum or in the countryside that has a single story book at home. The statistics are shocking. Yet what has been so impressive to see are the huge number of projects that our small donations can fund and the extent to which DfID has both ensured that what they initiate works with the grain of Kenyan culture while challenging traditions which are morally unacceptable, and similarly their focus on governance and transparency of spending.

A prime example of this is our support through them for Gender Based Violence Recovery Centres which provide education on the deplorable tradition of men beating their wives and support for women who have suffered. In a culture where most women are still the property of their husbands and fear seeking any formal help when they have been beaten or raped, the past few years have seen several initiatives to confront the culture. The government have also run a campaign called ‘Real men don’t beat their wives’ which has reportedly had a major impact, giving more women the confidence to speak out and seek help. There is a long way to go. When I asked a group of teachers about young girls of 12 or 13 who become pregnant and are expelled from school, there was a mixture of denial and indifference in the possibility of abuse, incest or coercion. I have spoken to elders who condemn the violent traditions but there are those of all ages who still support it.

The stories of corruption when it comes to international aid should not be ignored; but neither should the people who depend on that aid for their lives and their children’s lives, and neither should the voices of those older people who have a valuable perspective to bring.

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11 June 2012 10:59 AM

Ever since Jesus was left behind in Jerusalem, one of the top ten parent's nightmares is getting home to find that you are one child down. Such a story has seeped out today with the 8 year old Nancy Cameron being left behind at a pub after the Prime Minister and his family had been out for lunch with friends. Sam thought Nancy was with Dave; Dave thought Nancy was with Sam and when the Camerons met up back at home, she was with neither of them. For anyone who hasn't gone through this, the sheer panic that grips you when you find one of your children has gone missing cannot be overstated. This is no paralysing fear; every cell in your body adopts commando status as you begin to marshal your response, but I can remember the accompanying strangled, suffocating feelings when it happened to me - 12 years ago - as if it had been last week.

For all of us who are reunited with our absent child, we later laugh with friends as we recall the circumstances, our panic, our relief. But each one of those children, missed for minutes, are the lucky ones. Not (obviously) because they weren't kidnapped, but because they were missed even when it was just a matter of minutes. This story contrasts starkly with the report from the NSPCC that last year saw the largest ever number of calls about child neglect. 12,000 contacts with them between April 2011 and March 2012 were reporting suspected neglect: children wandering the streets at all hours and for many hours; asking neighbours for food as they were hungry; being maltreated. These are children who could be out of the home for long periods of time with no one knowing or even wondering where they were. This is not a new phenomenon, but the signs are that neglect is rising. We know that once again times are hard, but it's too simplistic to blame poverty. Charities such as Christians Against Poverty have revealed that one in ten families are in debt, but this is no reason for neglect and it's an insult to the poor to imply otherwise. At the other end of the scale, ask any public school Principal and they could tell you of wealthy families guilty of gross neglect: they pay the cheque for the school fees and consider that to be the end of their responsibilities.

The problem lies not in income but in the status of caring and parenting. Raising a child is the most important job that you can do, but it has become regarded by many as a second rate, spare time side-show to the rest of your life. The reasons for this slide are complex and the decline has occured over time, but essentially individualism has increasingly trumped sacrifice and responsibility. The media reporting today reflects the low priority we give to parenting. Statistics like "12,000 calls reporting neglect" should be top of the news hour, but they got a thirty second mention low down in a BBC summary.

We require nothing short of a culture change in Britain to raise the status of caring. A wholesale review of the tax, flexible leave and benefits systems needs to be combined with a high-level review of where we have undermined the different caring roles in society. Only then will we be able to begin to align the messaging and redeem our culture. We know in our hearts that caring for another human being, whether they are old or sick or a young child like Nancy is of essential importance - it's time our heads caught up so no one can be left in any doubt.

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01 June 2012 11:37 AM

Millions - billions if we count the world-wide audience - will stop to watch the celebrations for an elderly lady this weekend. The majority of us will stop what we are doing and observe with great pride and the highest esteem the procession on the Thames to celebrate sixty years of dedicated service by our faithful monarch.

In a country where lack of respect for older people has become an all too frequent feature of newspaper articles, this weekend I believe could mark a turning point. We will be celebrating a woman whose life transcends celebrity, whose commitment, dedication and humility are an inspiration to monarchists and republicans alike. For this is an opportunity for our nation not only to mark a long and faithful reign, but the selfless, obedient life of an old lady who has dedicated herself to serving her country and the Commonwealth.

In a society where to be called 'old' has become all but an insult, the Queen offers us the chance to redeem ourselves. She is, by dint of her age and conduct, an ambassador for the elderly; an old and wise leader that we should be encouraging all our children and grandchildren to look up to, not just because of her service, but because she is old. She offers us the chance to take stock, acknowledge the mistakes we have made and return an understanding of being worthy of respect to the meaning of 'old'.

There is a biblical proverb that says 'become wise by walking with the wise'. All those who know the Queen infer as much through having been with her, that they have become wiser through being in the presence of her wisdom. Most of us won't have the chance to meet her, but this weekend aside, I don't think that there are enough opportunities to be reminded of her stature and service. Wouldn't having her portrait in every school in the country be a great place to start? Some may resent the privileges of royalty, but the daily reminder that we have in this country an old lady who has invested her life in the service of others could sow a few seeds of respect in the hearts of the young.

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30 May 2012 3:53 PM

The result of the British Medical Association ballot of doctors has just been published with a majority voting for industrial action in protest of reforms to their pensions. Quite why so many doctors cannot see that this is a massive own goal is a mystery. At a time when millions are out of work, parents are struggling with household bills and the elderly have no reassurance of adequate social care, some doctors are showing that their concern is more for their pockets than their patients.

Many of my friends in medicine will be horrified and embarrassed at the thought of their colleagues striking, knowing that this action will tarnish them all. Surely up and down the land in months to come, GPs will rightly redden as they tell a patient they can't have a medicine or procedure on the NHS because there isn't enough money!

As the young doctor's group Remedy UK have previously said, action over pensions is "not morally justifiable". It ignores the economic crisis that we as a nation are facing and stays arrogantly quiet on the fact that doctor's pensions are still one of the best in UK. Not only this, but in their retirement they will still be on more than double the average wage.

Whilst the BMA are hastily saying that patients won't suffer, this can only be said from the head-in-sand ostrich position. Longed-for procedures and tens of thousands of appointments for which people have made arrangements will be cancelled, whilst the striking will achieve nothing because there is not enough money to meet their demands.

The irony is that it is a result of doctor's successes that many of us are living longer, notably doctors themselves who in a US study were shown to outlive lawyers and accountants. If there is any injustice in the pension reforms it is for those who are in blue-collar jobs who live in areas of lower life expectancy. Retirement for them may be short lived, as opposed to the twenty years or so anticipated by a doctor.

There will be no public sympathy. With an NHS pension scheme requiring a Treasury bail-out from 2013-14 (i.e. more of our tax-payers money), doctors need to accept that their deal is still one of the best around. If they persist with their action, they could find the public not only object, but find out what doctors are still getting and oppose that too.

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JULIA MANNING

Julia studied visual science at City University and became a member of the College of Optometrists in 1991. Her career has included being a visiting lecturer in at City University, visiting clinician at the Royal Free Hospital, working with Primary Care Trusts and a Director of the UK Institute of Optometry. She also specialised in diabetes and founded Julia Manning Eyecare, a practice for people with mental and physical disabilities. In 2006 she established 2020health.org, an independent Think Tank for Health and Technology. Research publications have covered public health, telehealth, workability, pricing of medicines, biotechology, NHS reform and fraud.